South Mountain Post Acute

In the surveyor’s words

From the most serious findings on record at South Mountain Post Acute, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF725Aug 19, 2026

  Based on resident and staff interviews, facility documentation, staffing records, and policy review, the facility failed to provide sufficient nursing staff to provide nursing and related services to meet residents' needs based on the number and acuity of the resident population. This deficient practice resulted in delayed staff response to a resident who required assistance and had the potential to result in delayed or unmet care needs for residents requiring staff assistance.Findings include:Review of the Payroll-Based Journal (PBJ) Staffing Data Report revealed that the facility triggered for excessively low weekend staffing during three reporting quarters in 2025, which affected the facility's staffing rating.Review of the facility assessment, revised February 11, 2026, revealed that… […]

• No harm, potential for more than minimal, patternF757Aug 20, 2025

  Based on clinical record review, interviews, and review of the facility's policy and procedures, the facility failed to ensure pain medications were administered in accordance with physician's orders for two out of twenty-three residents (#13 and #131). The deficient practice could result in the resident receiving unnecessary medications and being overmedicated.Findings include:Related to resident #13-Resident #13 was admitted to the facility on [DATE] with diagnoses that include Bipolar Disorder, type 2 diabetes, schizophrenia, and prior history of a stroke which has affected her right dominant side. […]

• No harm, potential for more than minimal, patternF812Jan 6, 2023

  Based on observations, staff interviews, and policy, the facility failed to ensure multiple food items were stored in accordance with professional standards. Findings include: During a walk through in the kitchen conducted on [DATE] at 8:24 a.m. with the Dietary Supervisor (staff #11), multiple observations were made in the large refrigerator, freezer, and dry storage: -a one-gallon container of sweet relish was observed with approximately a fifth of the relish remaining and there was no open date or use by date on the container. -,d+[DATE] size containers with diced onions, diced carrots, and diced tomatoes were observed with no preparation dates. -2 small plastic containers of ketchup dated [DATE] to [DATE]. […]

• No harm, potential for more than minimal, isolatedF880Aug 19, 2026

  Based on clinical record review, observations, interviews, and review of the facility's policies and procedures, the facility failed to implement and follow contact precautions and ensure contact precautions were discontinued in accordance with facility policy for three residents (#131, #157, and #158). The universe was 24. The deficient practice could lead to the spread of infectious organisms to other residents. Findings include:Regarding Resident #157-Resident #157 was admitted to the facility on [DATE] with diagnoses that included encounter for orthopedic aftercare following surgical amputation, enterocolitis due to clostridium difficile, and infection of amputation stump right lower extremity.Review of the Minimum Data Set (MDS) assessment list revealed the admission MDS was not yet… […]

• No harm, potential for more than minimal, isolatedF684Dec 29, 2025

  Based on observation, record review, staff interviews, and facility policy, the facility failed to ensure one resident (#33) received care and services necessary to attain or maintain their highest practicable physical well-being, as evidenced by failure to notify the provider when blood pressure medication was held and failure to obtain and document vital signs before hospitalization. The deficient practice could potentially limit the provider's ability to assess the resident's condition and potentially delay appropriate medical intervention. The sample size was 3. […]